What is the differential diagnosis and initial management for a middle-aged patient with acute chest pain and a history of hypertension and hyperlipidemia?

Differential Diagnosis of Acute Chest Pain in a Middle-Aged Patient with Hypertension and Hyperlipidemia

In a middle-aged patient with acute chest pain and cardiovascular risk factors, immediately rule out acute coronary syndrome, aortic dissection, and pulmonary embolism before considering less urgent diagnoses—obtain a 12-lead ECG within 10 minutes and measure high-sensitivity cardiac troponin immediately. 1

Life-Threatening Causes (Must Exclude First)

Acute Coronary Syndrome (STEMI/NSTEMI/Unstable Angina)

• Presentation: Retrosternal pressure, heaviness, or squeezing that builds gradually over minutes (not seconds), lasting ≥10 minutes, radiating to left arm, jaw, or neck 1, 2
• Associated symptoms: Diaphoresis, dyspnea, nausea, abdominal pain, or syncope 1, 2
• Key risk factors in your patient: Hypertension and hyperlipidemia significantly increase probability, along with male sex and middle age 1
• Critical action: ECG within 10 minutes; if nondiagnostic, repeat at 15-30 minute intervals during first hour 1, 3
• Pitfall: Normal initial ECG occurs in 1-6% of ACS patients—left circumflex or right coronary occlusions can be "electrically silent" 1, 3

Aortic Dissection

• Presentation: Sudden-onset "ripping" or "tearing" chest pain radiating to upper or lower back 1, 2
• Physical exam: Pulse differentials between extremities, blood pressure differential >20 mmHg, new aortic regurgitation murmur 2, 3
• High-risk factors: Hypertension (present in your patient), advanced age, atherosclerosis 4
• Imaging: Chest radiograph may show widened mediastinum; CT angiography of chest/abdomen/pelvis is diagnostic test of choice 1, 3

Pulmonary Embolism

• Presentation: Acute dyspnea with pleuritic chest pain 1, 2
• Physical exam: Tachycardia (>90% of patients), tachypnea 2, 3
• Risk factors: Immobility, recent surgery, malignancy, hypercoagulable state 3
• Imaging: CT chest with IV contrast to exclude PE 1

Tension Pneumothorax

• Presentation: Severe dyspnea, unilateral absence of breath sounds 2, 3
• Physical exam: Tracheal deviation, jugular venous distension, hypotension 3

Serious But Non-Immediately Fatal Cardiovascular Causes

Pericarditis

• Presentation: Sharp, pleuritic chest pain that worsens when supine and improves when leaning forward 1, 2
• Physical exam: Friction rub on examination, fever 2
• ECG findings: Diffuse ST elevation, PR depression 4

Myocarditis

• Presentation: Chest pain, fever, signs of heart failure, S3 gallop 2

Valvular Disease

• Consider: Aortic stenosis, aortic regurgitation, hypertrophic cardiomyopathy 2
• Physical exam: Murmurs, signs of heart failure 1

Pulmonary Causes

Pneumonia

• Presentation: Chest pain with fever, productive cough, dyspnea 1
• Imaging: Chest radiograph shows infiltrate 1

Pleuritis

• Presentation: Sharp, pleuritic chest pain worsened by inspiration 1

Pneumothorax (Non-Tension)

• Presentation: Dyspnea and pain on inspiration, unilateral decreased breath sounds 1, 5

Gastrointestinal Causes

Gastroesophageal Reflux/Esophageal Spasm

• Presentation: Burning retrosternal pain related to meals, relieved by antacids 1, 2
• Critical pitfall: Esophageal spasm responds to nitroglycerin—do NOT use nitroglycerin response as diagnostic criterion for cardiac ischemia 2, 3

Peptic Ulcer Disease

• Presentation: Epigastric pain, may radiate to chest 1

Pancreatitis/Biliary Disease

• Presentation: Upper abdominal/epigastric pain radiating to back or chest 1

Musculoskeletal Causes

Costochondritis

• Presentation: Tenderness of costochondral joints on palpation, pain reproducible with chest wall pressure 1, 2
• Key feature: Pain affected by palpation, breathing, turning, twisting, or bending 2, 5
• Note: Most common diagnosis when cardiac causes excluded 2

Cervical Radiculopathy

• Presentation: Pain radiating from neck, positional component 1

Psychiatric Causes

• Diagnoses: Panic attack, anxiety disorders, somatoform disorders 1
• Note: These are diagnoses of exclusion after life-threatening causes ruled out 1

Initial Management Algorithm

Immediate Actions (Within 10 Minutes)

1. 12-lead ECG within 10 minutes of arrival 1, 3
2. High-sensitivity cardiac troponin immediately upon presentation 1, 3
3. Vital signs including oxygen saturation, blood pressure in both arms 3
4. Focused physical examination for pulse differentials, heart sounds, lung sounds, signs of heart failure 1, 3

Serial Monitoring

• Repeat ECG at 15-30 minute intervals during first hour if initial ECG nondiagnostic and symptoms persist 1, 3
• Serial troponin at 1-2 hours (if high-sensitivity assay) or 3-6 hours (if contemporary assay) 1, 3
• Consider posterior leads (V7-V9) if intermediate-to-high suspicion for posterior MI 3

Risk Stratification

• Apply validated risk scores: TIMI or GRACE 2.0 to guide management intensity 3, 4
• High-risk features requiring immediate intervention: Continuing chest pain, severe dyspnea, syncope/presyncope, palpitations, hemodynamic instability 1

Imaging Based on Clinical Suspicion

• Chest radiograph: Useful to identify pulmonary causes, widened mediastinum (aortic dissection), pneumothorax 1
• CT chest with IV contrast: If suspicion for PE or aortic dissection 1, 3
• Transthoracic echocardiography: If suspicion for pericardial effusion, tamponade, regional wall motion abnormalities 1

Critical Pitfalls to Avoid

• Do not dismiss atypical presentations: Older patients (≥75 years), women, and patients with diabetes/renal insufficiency/dementia frequently present with atypical symptoms including isolated dyspnea, nausea, or epigastric pain without classic chest pain 1, 2, 3
• Do not rely on single normal ECG: Up to 6% of ACS patients have normal initial ECG 1, 3
• Do not use nitroglycerin response diagnostically: Esophageal spasm and other conditions also respond to nitroglycerin 2, 3
• Do not delay transfer for office troponin testing: If ACS suspected, immediate ED referral by EMS is required 1, 3

Disposition Decisions

Immediate ED Transfer by EMS

• Clinical evidence of ACS with high-risk features 1, 3
• Hemodynamic instability 3, 5
• New ECG abnormalities suggesting ischemia 3, 5

Consider Observation/Admission

• Intermediate risk by structured assessment with abnormal initial workup 3
• Recurrent symptoms during observation 3
• Elevated troponin levels 3

Outpatient Management Acceptable

• Low risk by structured assessment 3
• Normal ECG and troponin 3
• No high-risk features 3
• Clear alternative diagnosis (e.g., costochondritis with reproducible tenderness) 2, 5